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Constipation
Abdominal in Adults
Pain, Acute
Pathophysiology
Visceral pain comes from the abdominal viscera, which are inner-
vated by autonomic nerve fibers and respond mainly to the sensations
of distention and muscular contractionnot to cutting, tearing, or local
irritation. Visceral pain is typically vague, dull, and nauseating. It is
poorly localized and tends to be referred to areas corresponding to the
embryonic origin of the affected structure. Foregut structures (stomach,
duodenum, liver, and pancreas) cause upper abdominal pain. Midgut
structures (small bowel, proximal colon, and appendix) cause perium-
bilical pain. Hindgut structures (distal colon and GU tract) cause lower
abdominal pain.
Somatic pain comes from the parietal peritoneum, which is inner-
vated by somatic nerves, which respond to irritation from infectious,
chemical, or other inflammatory processes. Somatic pain is sharp and
well localized.
Referred pain is pain perceived distant from its source and results
from convergence of nerve fibers at the spinal cord. Common examples
of referred pain are scapular pain due to biliary colic, groin pain due to
renal colic, and shoulder pain due to blood or infection irritating the
diaphragm.
Etiology
Many intra-abdominal disorders cause abdominal pain (see Fig. 1);
some are trivial but some are immediately life threatening, requiring
rapid diagnosis and surgery.
Immediate life threats include
Ruptured abdominal aortic aneurysm
Perforated viscus
Mesenteric ischemia
Ruptured ectopic pregnancy
Other serious and urgent causes include
Intestinal obstruction
Appendicitis
Severe acute pancreatitis
Several extra-abdominal disorders also cause abdominal pain
(see Table 1).
Abdominal pain in neonates, infants, and young children has
numerous causes not encountered in adults, including meconium peri-
tonitis, pyloric stenosis, esophageal webs, volvulus of a gut with a
common mesentery, imperforate anus, intussusception, and intestinal
obstruction from atresia.
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RIGHT LOWER
QUADRANT PAIN
Appendicitis
Cecal diverticulitis LEFT LOWER
Meckels QUADRANT PAIN
diverticulitis Sigmoid
Mesenteric adenitis diverticulitis
GU
Testicular torsion
INFECTIOUS
Herpes zoster
METABOLIC
Alcoholic ketoacidosis
Diabetic ketoacidosis
Porphyria
Sickle cell disease
THORACIC
Myocardial infarction
Pneumonia
Pulmonary embolism
Radiculitis
TOXIC
Evaluation
Evaluation of mild and severe pain follows the same process,
although with severe abdominal pain, therapy sometimes proceeds
simultaneously and involves early consultation with a surgeon.
History and physical examination usually exclude all but a few possi-
ble causes, with final diagnosis confirmed by judicious use of labora-
tory and imaging tests. Life-threatening causes should always be ruled
out before focusing on less serious diagnoses. In seriously ill patients
with severe abdominal pain, the most important diagnostic measure
may be expeditious surgical exploration. In mildly ill patients, watch-
ful waiting may be best.
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HISTORY
History of present illness usually suggests the diagnosis (see
Table 2). Of particular importance are pain location (see Fig. 1) and
characteristics, history of similar symptoms, and associated symptoms.
Concomitant symptoms such as gastroesophageal reflux, nausea, vom-
iting, diarrhea, constipation, jaundice, melena, hematuria, hemateme-
sis, weight loss, and mucus or blood in the stool help direct subsequent
evaluation.
Past medical history should ascertain known medical conditions
and previous abdominal surgeries. Women should be asked whether
they are pregnant. A drug history should include details concerning
prescription and illicit drug use as well as alcohol. Many drugs cause
GI upset. Prednisone or immunosuppressants may inhibit the inflam-
matory response to perforation or peritonitis and result in less pain
and leukocytosis than might otherwise be expected. Anticoagulants
can increase the chances of bleeding and hematoma formation. Alcohol
predisposes to pancreatitis.
(continued)
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PHYSICAL EXAMINATION
The general appearance is important. A happy, comfortable-appearing
patient rarely has a serious problem, unlike one who is anxious, pale,
diaphoretic, or in obvious pain. BP, pulse, state of consciousness, and
other signs of peripheral perfusion must be evaluated. However, the
focus of the examination is the abdomen, beginning with inspection
and auscultation, followed by palpation and percussion. Rectal exami-
nation and pelvic examination (for women) to locate tenderness,
masses, and blood are essential.
Palpation begins gently, away from the area of greatest pain, detect-
ing areas of particular tenderness, as well as the presence of guarding,
rigidity, and rebound (all suggesting peritoneal irritation) and any
masses. Guarding is an involuntary contraction of the abdominal mus-
cles that is slightly slower and more sustained than the rapid, volun-
tary flinch exhibited by sensitive or anxious patients. Rebound is a
distinct flinch upon brisk withdrawal of the examiners hand. The
inguinal area and all surgical scars should be palpated for hernias.
INTERPRETATION OF FINDINGS
Some findings strongly suggest certain disorders.
Distention, especially when surgical scars, tympany to percussion,
and high-pitched peristalsis or borborygmi in rushes are present,
strongly suggests bowel obstruction.
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RED FLAGS
Severe pain
Signs of shock (eg, tachycardia, hypotension, diaphoresis, confusion)
Signs of peritonitis
Abdominal distention
TESTING
Tests are selected based on clinical suspicion.
Urine pregnancy test for all women of childbearing age
Selected imaging tests based on suspected diagnosis
Standard laboratory tests (eg, CBC, chemistries, urinalysis) are
often done but are of little value due to poor specificity; patients with
significant disease may have normal results. Abnormal results do not
provide a specific diagnosis (the urinalysis in particular may show
pyuria or hematuria in a wide variety of conditions), and they can also
occur in the absence of significant disease. An exception is serum
lipase, which strongly suggests a diagnosis of acute pancreatitis when
elevated. A bedside urine pregnancy test should be done for all women
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Treatment
Some clinicians feel that providing pain relief before a diagnosis is
made interferes with their ability to evaluate. However, moderate
doses of IV analgesics (eg, fentanyl 50 to 100 mg, morphine 4 to 6 mg)
do not mask peritoneal signs and, by diminishing anxiety and discom-
fort, often make examination easier.
KEY POINTS